Basic Information
| Provider Information | |||||||||
| NPI: | 1922071687 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TRI STATE GASTROENTEROLOGY, P.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 27340 | ||||||||
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| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850617340 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6029439200 | ||||||||
| FaxNumber: | 6022163000 | ||||||||
| Practice Location | |||||||||
| Address1: | 1225 HANCOCK RD | ||||||||
| Address2: | SUITE 205 | ||||||||
| City: | BULLHEAD CITY | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 864425948 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9287631680 | ||||||||
| FaxNumber: | 9287638511 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/10/2006 | ||||||||
| LastUpdateDate: | 12/06/2007 | ||||||||
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| AuthorizedOfficialLastName: | JAN | ||||||||
| AuthorizedOfficialFirstName: | ALTAF | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9287631680 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
No ID Information.